View as PDF version
Intrahospital
transports can be very hazardous for patients (see our many columns on the
issue listed at the end of todays column). They are especially risky for
critical care patients. Many of those transports are to the Radiology Suite or
the MRI suite, areas weve also previously identified as being at high
risk for patient safety issues. Lina Bergman, a PhD critical care nurse in
Sweden, recently did a thesis on the hazards of intrahospital transports that
adds to our understanding of the risks of these transports (Bergman
2020).
For the thesis, she and
her research team analyzed almost 500 intrahospital transports of patients from
2 ICUs in a Swedish hospital, one a general/trauma ICU (18 beds) and the other
a neurological ICU (8 beds). A typical transport team consisted of a minimum of
2 individuals but might have as many as 5 or more. A researcher or research
assistant did observations during intrahospital transports and also performed semi-structured interviews with
both intensive care staff (nurses and physicians) and patients.
She utilized a conceptual model based on the
5 components of the SEIPS (Systems Engineering Initiative for Patient Safety)
model:
A total of 51 intrahospital transports over a
6-week period constituted the data sample. 62% of the transports were for CT
scans. 80% of transported patients were on mechanical ventilation, 61% were
receiving continuous sedation, and 51% were on vasopressors.
Examples of ineffective teamwork included
loss of information between team members or tasks not being performed as
intended. Examples of task hazards included interruptions and distractions
during preparation for transport that resulted in skipped safety checks or
prolonged preparation times. Examples of tools and technologies hazards
included equipment errors, such as disconnection of tubes or lines, Problems
with equipment and workplace design often led to workarounds.
Themes
were grouped into 2 main categories:
In the second category, staff noted that
knowledge and experience in performing transport-related functions and
individual skills to anticipate and predict safety scenarios were important.
Moreover, they recognized that the collective competence of the transport
team was especially important. Only a third of interviewees said they used
a checklist during the intrahospital transports, but 64% of these found use of
the checklists helpful.
When the researchers assessed the opinions of
nurses and physicians, they found a pattern we have seen previously nurses
wanted more interprofessional collaboration, whereas physicians were satisfied
with the current status.
The researchers also interviewed patients and
found they, in general, were very satisfied with the transports and trusted
their caregivers. The healthcare professionals, on the other hand, found the
transports to be demanding and sometimes unsafe.
The Bergman thesis does include a 24-item
scale that can be used for evaluation of intrahospital transports of ICU patients.
It can serve as a good quality improvement tool.
Bergman provides several practical
recommendations for intrahospital transports, based on the research
observations:
We really like her idea of a team timeout
prior to departure from the ICU. We are a big fan of huddles. This is an
opportunity not only to say Do we have everything we
need? and go over the Ticket to Ride checklist, but also to say Are there
any things we might anticipate?. Thats also a good time to ask
Have we communicated with the receiving unit?. Hospital personnel on the
receiving end also be familiar with the transport equipment and status of the
patient. That brings us to another thing wed emphasize:
the need for an appropriate handoff prior to and following the
transport. Lets say you are transporting a critically
ill patient to the Radiology suite for a CT scan. You should discuss with the
radiology nurse or radiology staff whether your patient is on oxygen, being
ventilated, whether the patient will need sedation for the procedure, what
sorts of medications are running in various lines, etc. and discuss what events
might be anticipated.
The Bergman thesis broke down the 365 safety
hazards into 5 categories but did not provide individual description of each
hazard. But you can go back to our October
22, 2013 Patient Safety Tip of the Week How
Safe Is Your Radiology Suite? for a comprehensive discussion of all the things that can go
wrong when a patient is sent to the radiology suite. That column and several
others demonstrate a wide variety of hazards you might encounter during an
intrahospital transport. We also refer
you back to our August 25, 2015 Patient Safety Tip of the Week Checklist
for Intrahospital Transport for discussion about the many factors contributing to incidents related
to intrahospital transports. These include equipment failures, oxygenation
issues, battery/power issues, and things like attention to patient hydration.
And dont forget the problems that arise when sending
diabetic patients off for substantial periods of time (what to do with their insulin,
planning for meals, etc.).
In
our August 25, 2015 Patient Safety Tip of the Week Checklist
for Intrahospital Transport we noted 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 our March 13, 2012 Patient Safety Tip of
the Week Medical
Emergency Team Calls to Radiology we noted a series of articles by Lora K. Ott and
colleagues (Ott 2012, Ott 2011a, Ott 2011b) that looked at medical
emergency team/rapid response team calls to the radiology suite and analyzed
patient factors related to those calls. The percentages in the papers differ,
presumably because the time frames for each were different, but the most recent
paper appears to account for all the cases over a two-year time period so well use those statistics. The
majority of the calls (60%) were for patients not from the ICUs and for
almost half they occurred on the patients first day in the hospital. The
authors speculate that this could be due to several reasons: (1) ICU patients
are recognized to be more at risk and are more likely to be accompanied to
radiology by nursing staff (2) the subtler evolving signs of clinical
deterioration may not have been appreciated in the patients from the general
units who are not as closely monitored. The majority had a Charlson
comorbidity index equal to or greater than 4 and about a third each had nasal
cannula oxygen, dyspnea, or tachycardia.
The nature of the events in the radiology
suite were primarily cardiac in 41%, respiratory in 29%, and neurological in
25% and most required a higher level of care after the event. 44% of the calls
involved patients undergoing CT scan and 22% MRI scanning. That should not be
surprising, given our many prior articles on safety issues in the radiology
suite. During either procedure the patient is
relatively isolated from monitoring staff for periods of time. In addition,
sedation may be used to facilitate completion of some of those studies.
Dislodging of catheters, tubes and lines during
transfer to the CT/MRI platforms could also play a role. Also, the nature of
the underlying condition necessitating the CT or MRI scan may also predispose
these patients to the types of deterioration seen. In one of the earlier papers
(Ott 2011b)
neurological causes of deterioration were more frequent so its not surprising
that many of these would have occurred during CT or MRI.
In one of the articles (Ott 2011b) peak time for such
events was between 10 AM and noon. The authors ascribe this interesting
temporal trend as most likely reflecting detection on morning rounds of
symptoms and signs necessitating the diagnostic studies.
One
of 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
ICUs 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, similar to the
Bergman study, 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.
Our March
31, 2020 Patient Safety Tip of the Week Intrahospital Transport
Issues in Children looked
at adverse events during intrahospital transport of critically ill children and
highlighted a study by Haydar et al. (Haydar 2019). Respiratory
and airway events were the most common type of adverse event. Hypothermia
was common in infants. They also found instances of emergent tracheostomy,
pneumothorax, and cardiac arrest. One transport-associated death was reported.
One hazard we had not commented upon often
enough in intrahospital transports is hypothermia. We did discuss the
risk of hypothermia in interhospital transfers (see our October 30, 2018 Patient Safety Tip of the
Week Interhospital Transfers). In our January 7, 2020 Patient
Safety Tip of the Week Even More Concerns About MRI
Safety we discussed a study that showed most
children who undergo MRI while under anesthesia experience hypothermia at some
point during the procedure (Cronin 2019). Children, particularly infants, are especially prone to hypothermia. Nevertheless, you should consider
the possibility that your patient might develop hypothermia during a transport,
particularly one that might be prolonged, and take appropriate steps to keep
the patient warm.
Apparently only about a third of transports
in the Bergman study used checklists. Planning for and implementing
transports is greatly facilitated by use of the Ticket to Ride
checklist. The original Ticket to Ride checklist was developed to ensure that
patients being transported had adequate oxygen supplies, since some studies
showed that over half of patients transported to sites like the radiology suite
ran out of oxygen. But the Ticket to Ride checklist has been expanded to
include many other considerations for events that might happen during and after
a transport (see our many columns on Ticket to Ride listed below).
A Ticket to Ride checklist for a patient
returning to a med/surg unit from the OR or PACU must
include not only items pertinent to the procedure and recovery that just took
place, but must also consider issues from before the surgery or procedure. For
example, were certain medications withheld prior to the surgery? Do they need
to be restarted? Is there physiologic monitoring that needs to be restarted?
In
our August 25, 2015 Patient Safety Tip of the Week Checklist
for Intrahospital Transport we discussed a checklist for intrahospital transport of critically ill
patients developed by clinical researchers in the Netherlands (Brunsveld-Reinders 2015). When
they prospectively monitored transports, they found that in 26% of 503
transports to Radiology one or more incidents occurred.
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. Weve 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/IVs. 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 good Ticket to Ride type checklist for
intrahospital transport should cover all three phases of transport:
pre-transport, during-transport, and post-transport (Jarden 2010, Brunsveld-Reinders 2015).
One question to include on the post-transport section of a Ticket to Ride checklist
is Are there any medications or monitoring that need to be restarted on this
patient?.
Ticket to Ride checklists also should be customized
to reflect both patient-related factors and factors related to the destination
or nature of the procedure the patient is being transported for. For example,
on an ICU patient transport you probably dont need items for wandering risk or
suicide risk that you would want on transporting a confused patient from a
med/surg unit or a depressed patient on a behavioral health unit. And, while we
recommend at item about risk of hypothermia for most patients, that item is
extremely important to include on infants and young children. And your
checklist would differ for a patient going to Radiology for simple radiographs compared
to a patient who might need sedation for a CT scan or MRI scan.
One extremely important question is missing
in the Bergman thesis: how many of the transports were indicated in the first
place? Every time we do a root cause analysis (RCA) on an intrahospital
transport that had an adverse event, the first question we ask is Was the
transport indicated?. Not uncommonly, we find that the indications for the
test or procedure for which the transport was undertaken were iffy at best. One
set of statistics we like to cite is that by Beckmann et al. (Beckmann
2004). They
note that studies suggest 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 likely to change patient management.
In
our August 25, 2015 Patient Safety Tip of the Week Checklist
for Intrahospital Transport we discussed the 5 Ws
of intrahospital transport (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 patients 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?. Days 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.
The majority of transports of ICU patients in the Bergman
thesis were for CT scans. Our many columns on patient safety in the Radiology
Suite or the MRI Suite (see lists below) stress that the incidents there are
not usually related to the imaging study itself. Rather, these are patients
with complex medical conditions, often unstable, who have multiple monitoring
needs and may have multiple lines and tubes and are receiving multiple
medications, oxygen, or other therapies. Given that so many ICU patient
transports are for CT scanning, some hospitals have considered use of portable
CT scans for this population. In our September 16, 2008 Patient Safety Tip of
the Week More
on Radiology as a High Risk Area we noted a study from the Cleveland Clinic
that demonstrated the cost effectiveness of having a dedicated portable CT
scanner to scan ICU patients.
Its
worth reiterating many of the points in our August 25, 2015 Patient Safety Tip
of the Week Checklist
for Intrahospital Transport. 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 ICUs 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 2005). Well also bet that the percentage of incidents related to
transports to the MRI suite has been increasing as MRI scanning has superseded
CT scanning for so many conditions.
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 1980s and 1990s
that showed rates of transport incidents as high as 70%. A paper by Smith et al
(Smith 1990)
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
authors had previously noted an incidence of 3.7% (Van Velsen 2011) but
when they prospectively monitored transports (Brunsveld-Reinders 2015)
they found that in 26% of 503 transports to Radiology one or more incidents
occurred.
Another study (Parmentier-Decrucq 2013)
found that 45.8% of 262 intrahospital transports were associated with adverse
events. In 16.8% of all intrahospital transports the adverse event was
considered serious for the patient. Risk factors were ventilation with positive
end-expiratory pressure >6 cmH2O, sedation before transport, and fluid
loading for intrahospital transports. Treatment modification before transport
was also a risk factor identified.
Intrahospital transports have 3 phases:
before, during, and after. Unfortunately, the after phase is often either
neglected or poorly managed. A recent case presentation in the AORN Journal (AORN
2020) illustrates the latter. A 4 y.o. boy underwent intestinal surgery under general anesthesia.
The procedure was uneventful, he was extubated in the OR, and sent to the PACU.
Continuous pulse oximetry was ordered for 24 hours because of his age and long
duration of surgery. Once stable in the PACU, he was transferred to the
inpatient unit. Pulse oximetry was disconnected during the transport, which
took about 10 minutes. Apparently, the only communication from the transporter
was that the patient was now in a room. The receiving nurse had been told the
procedure was uneventful and the patient stable, so she did not perform an
evaluation right away. A few minutes later, she placed him on pulse oximetry
and realized that he was markedly hypoxic. Oxygen was administered immediately but
he became bradycardic and hypotensive and went into cardiac arrest. He was
resuscitated but left with significant neurological damage as
a result of hypoxic brain injury.
The discussion centered on several key
issues. Obviously, communication issues were critical. Pulse oximetry was
discontinued during the transport and was presumed to be started on arrival at
the med/surg unit. Knowledge and skills clearly played a role as well.
The transporter stated that although he
thought the patient was having difficulty breathing during the transport, he
did not voice his concern because he had been assured the boy was stable and was
not confident in his own judgment. That reluctance to speak up also is a
reflection on the safety culture of the hospital. And it illustrates another
key component of intrahospital transfers the patient must be assessed before
and after the transport. And it notes that use of non-medical personnel for
transports is still fairly widespread.
Intrahospital transports, whether involving
critical care patients or others, need to be undertaken with considerable
planning, communication, and teamwork. You need to ensure that you have systems
in place to ensure the safety of the patients and tools like the Ticket to
Ride checklists may facilitate safe transports. And dont
forget there are 3 phases to intrahospital transports before,
during, and after the transport.
Some
of our prior columns on intrahospital transports and 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:
References:
Bergman L, Patient safety during
intrahospital transports in intensive care: Hazards, experiences
and future measurements. (Thesis, Gothenburg University). BrandFactory
2020; Gothenburg, Sweden (2020)
https://gupea.ub.gu.se/handle/2077/63248
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
http://patientsafety.pa.gov/ADVISORIES/Pages/200509_11.aspx
Ott LK, Pinsky MR, Hoffman LA, et al. Medical
emergency team calls in the radiology department: patient characteristics and
outcomes. BMJ Qual Saf 2012; published online ahead
of print March 2, 2012
http://qualitysafety.bmj.com/content/early/2012/03/01/bmjqs-2011-000423.short?g=w_qshc_ahead_tab
Ott LK, Hoffman LA, Hravnak
M. Intrahospital Transport to the Radiology Department: Risk for Adverse
Events, Nursing Surveillance, Utilization of a MET, and Practice Implications. Journal of Radiology Nursing 2011;
30(2): 49-54
http://www.radiologynursing.org/article/S1546-0843%2811%2900038-1/abstract
Ott LK, Hravnak M,
Clark S, Amesur NB. Patients Instability, Emergency
Response, and Outcomes in the Radiology Department.
Am J
Crit Care November 2011; 20(6): 461-469
http://ajcc.aacnjournals.org/content/20/6/461
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
https://link.springer.com/article/10.1007/s00134-004-2177-9
Haydar B, Baetzel A, Elliott A, et al. Adverse Events During
Intrahospital Transport of Critically Ill Children. A Systematic Review.
Anesthesia & Analgesia 2019; Published ahead of print December 16, 2019
Cronin JA, Shen .,
Rana S, et al. Association Between Magnetic Resonance Imaging in Anesthetized
Children and Hypothermia. Pediatric Quality & Safety 2019, 4(4): e181
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6708655/
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)
http://www.ccforum.com/content/19/1/214
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
Day D. Keeping Patients Safe During
Intrahospital Transport. Crit Care Nurse
2010; 30: 18-32
http://ccn.aacnjournals.org/content/30/4/18.full
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
http://www.ccforum.com/content/15/S1/P535
Smith I, Fleming S, Cernaianu
A. Mishaps during transport from the intensive care unit. Critical Care Medicine.
1990; 18(3):278-281
Parmentier-Decrucq
E, Poissy J, Favory R, et
al. Adverse events during intrahospital transport of critically ill patients:
incidence and risk factors. Ann Intensive Care 2013; 3: 10
https://annalsofintensivecare.springeropen.com/articles/10.1186/2110-5820-3-10#citeas
AORN (Association of periOperative
Registered Nurses). Anonymous.
Adverse event during intrahospital transport: The official voice of
perioperative nursing the official voice of perioperative nursing. AORN Journal
2020; 111(5): 577-579
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13013
Print PDF version
http://www.patientsafetysolutions.com/